Conducting a systems review of pressure ulcers in the intensive care unit

Summary

Pressure ulcers within the intensive care unit (ICU) have long been recognised as a persistent and complex patient safety issue. Critically ill patients are particularly vulnerable due to immobility, compromised perfusion (the process of blood delivery to the tissues), nutritional deficits and the presence of invasive medical devices.[1] Despite the implementation of prevention protocols, pressure ulcers continue to occur, suggesting that the problem extends beyond individual clinical actions and into the broader healthcare system.[2]

Recent UK-based studies have reinforced this view. For example, a national prevalence study found that pressure ulcers remain common in critical care, with medical device-related injuries accounting for a significant proportion.[3] Similarly, Health Innovation East highlighted the variability in outcomes across NHS settings, underscoring the need for system-wide approaches tailored to local contexts.[4]

In this blog, Patient Safety Learning's Associate Director Claire Cox shares how she adopted a systems approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model to review pressure ulcers.

Content

Before initiating this review, I recognised that pressure ulcers in the ICU were not solely a clinical concern—they reflected broader systemic issues. Patients in intensive care are critically unwell, frequently immobile and often unable to reposition themselves. Their skin integrity is compromised by factors such as impaired circulation, nutritional deficits and the presence of medical devices.

Staff operate under considerable pressure, balancing urgent, life-saving interventions with preventative care. Routine practices, such as repositioning and skin assessments, must be prioritised alongside emergencies. Documentation is fragmented—split between paper and electronic systems—resulting in communication challenges and planning inconsistencies. Access to pressure-relieving equipment varies, and escalation pathways are not always clearly defined.

These challenges are not attributable to individuals. Rather, they are indicative of a system that does not consistently enable safe care. For this reason, I adopted a systems approach to explore how environmental conditions, tools, tasks and organisational structures interact—and where they may be misaligned.

The aim was to move beyond attributing fault and instead identify the conditions that increase the likelihood of harm and how these might be addressed.

Applying the SEIPS framework

To guide this review, I used the SEIPS model. SEIPS is a human factors framework that examines how components of a work system—people, tasks, tools and technology, physical environment, and organisational conditions—affect processes and outcomes in healthcare.[5] It supports a holistic understanding of safety by focusing on system design rather than individual performance.

Step 1: Framing the review

I began by clarifying the scope and purpose. The objective was to examine the gap between 'work as imagined' (WAI)—the protocols and guidelines—and 'work as done' (WAD)—the realities of clinical practice. This approach enabled a deeper understanding of how pressure ulcer prevention is enacted in the ICU.

A thematic review methodology was also selected to synthesise insights from multiple sources:

• patient safety incident reports
• staff interviews and informal conversations
• observations of workflow and environmental factors.

Step 2: Gathering insights

I spent time in the ICU, observing care delivery and engaging with staff across disciplines. I listened for patterns, inconsistencies and adaptations—those moments where staff had to improvise or navigate ambiguous systems.

Documentation practices were reviewed, with attention to the coexistence of paper and digital records and the implications for communication and care planning. I examined how pressure ulcer risk was assessed, how referrals to tissue viability nurses were managed, and how equipment was accessed and escalated.

Step 3: Mapping the system

Using the SEIPS framework, I mapped the key components of the ICU system:

• People: Skilled, responsive staff working under pressure.
• Tasks: Complex care routines with competing demands.
• Tools and technology: Mixed documentation systems and variable equipment availability.
• Environment: A newly established ICU with evolving workflows.
• Organisation: Gaps in escalation protocols and support structures.

This mapping revealed areas of misalignment—where expectations diverged from practice, and where staff were compensating for systemic limitations.

Step 4: Synthesising findings

The analysis highlighted several interconnected challenges:

• Absence of standardised risk assessment and escalation guidance.
• Delays in accessing specialist mattresses.
• Inconsistent documentation and communication pathways.
• Limited visibility and support from tissue viability teams.

These issues were not isolated; they reflected broader systemic vulnerabilities and opportunities for improvement.

Step 5: Developing recommendations

Based on these insights, I proposed a series of actionable recommendations:

• Standardise surface provision and mattress escalation protocols.
• Enhance visual guidance for managing pressure damage.
• Streamline access to advanced support surfaces.
• Strengthen tissue viability support and referral pathways.
• Clarify documentation expectations and risk assessment procedures.

Step 6: Sharing and reflecting

The findings were shared with ICU staff and senior leadership. Feedback was overwhelmingly positive—staff felt their experiences were acknowledged and leaders appreciated the systemic perspective. The review contributed to averting a Regulation 28 notice (Prevention of Future Deaths report) and sparked interest in applying systems-thinking more broadly.

Throughout the process, I remained grounded in curiosity. I did not begin with assumptions; instead, I asked, observed and listened. This mindset was instrumental in uncovering meaningful insights and fostering constructive dialogue.

References

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers.. 2019.
2. Jackson D, Durrant L, Walthall H. et al. Pain associated with pressure injury: A qualitative study of community-based, home-dwelling individuals. J Advanced Nursing, 2017; 73(12): 3061-9.
3. Rubulotto F, Brett S, Boulanger C, et al. Prevalence of skin pressure injury in critical care patients in the UK. BMJ Open, 2022  ;12: e057010. doi:10.1136/bmjopen-2021-057010.
4. Parkinson E, Leming S, Elmore N, Martin S. NHS Wound Care: Rapid evidence scoping review. Health Innovation East, April 2024
5. Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. BMJ Quality & Safety 2006.

Related reading on the hub:

• Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin
• PSIRF planning – Pressure ulcer example scenario
• Application of SEIPS and AcciMap to a patient safety incident
• Patient Safety: Emerging Applications of Safety Science
• SEIPS in action